The Advanced Practice Provider will conduct comprehensive patient assessments and develop individualized care plans for patients with chronic diseases in an inpatient setting. They will also collaborate with interdisciplinary teams to manage complex symptoms, facilitate transitions of care, and provide palliative care consultations.
Requirements summary
Candidates must hold a current Texas Nurse Practitioner or Physician Assistant license and possess national certification. The role requires the ability to perform clinical tasks in a high-stress environment and maintain current prescriptive authority.
professional certificateCare PlanningMentoringPatient AssessmentRegulatory CompliancePatient EducationClinical DocumentationCritical ThinkingInterdisciplinary CollaborationElectronic Medical RecordSymptom ManagementPalliative CareDiabetes ManagementAdvance Care PlanningChronic Disease ManagementInsulin Titration
Job description
Advanced Practice Provider - Chronic Disease Management
Summary of Essential Functions
Provides comprehensive acute and chronic patient care across inpatient setting
Assesses patient health status and determines diagnostic and therapeutic needs
Documents patient information accurately within the medical record
Educates patients and families to support continuity of care
Collaborates with physicians and interdisciplinary teams
Acts as a liaison between providers, hospital, and community
Educational Requirements
Current Texas Nurse Practitioner License or Physician Assistant (PA)
Effective verbal and written communication skills
Licenses and Certifications
Meets Texas Board requirements for Advanced Practice Nurses or Physician Assistant
Current prescriptive authority (DEA/DPS as applicable)
National certification as an Advanced Practice Nurse or Physician Assistant
ACLS/PALS preferred
Knowledge/Skills/Abilities
Clinical experience preferred
Strong critical thinking skills
Completion of hospital orientation requirements
Physical Requirements
Ability to stand for extended periods and perform clinical tasks
Ability to lift up to 50 pounds
Ability to work in high-stress environments
Exposure to bloodborne pathogens
Duties and Responsibilities
Conduct comprehensive patient assessments, including medical history, physical examination, and review of diagnostic data to guide clinical decision-making
Develop, implement, and adjust individualized, evidence-based care plans in collaboration with the interdisciplinary team and supervising physician as required
Provide patient and family education to improve understanding of disease processes, treatment plans, and expected outcomes
Document all patient encounters accurately and timely in the electronic medical record (e.g., EPIC), ensuring compliance with regulatory and organizational standards
Collaborate with physicians, nursing staff, case management, social work, and other disciplines to ensure coordinated, patient-centered care
Perform palliative care consultations for patients with life-limiting illnesses
Lead and support goals-of-care discussions, including advance care planning and code status clarification
Assess and manage complex symptom burden
Deliver compassionate, comfort-focused care for patients designated as comfort care, ensuring symptom relief, dignity, and alignment with established goals of care
Provide emotional support to patients and families
Coordinate care with hospice and community palliative resources
Manage inpatient diabetes care, including glycemic control and insulin titration
Utilize clinical tools (e.g., EndoTool) to support insulin management
Collaborate with nursing on insulin and glucose monitoring practices
Address barriers to glycemic control
Coordinate discharge planning and outpatient referrals
Facilitate transitions of care and communicate with outpatient providers
Participate in interdisciplinary rounds and discharge planning
Identify high-risk patients and implement interventions
Provide staff education and support when needed
Participate in program development and workflow improvement
Serve as a clinical resource and mentor
Contribute to quality improvement initiatives and monitor key metrics
Maintain licensure and certifications
Adhere to scope of practice and agreements
Uphold confidentiality and professional standards
Performs all other tasks/responsibilities as necessary
